Outcome measures and needs assessment tools for schizophrenia and related disorders

Examining a sentiment algorithm on session patient records in an eating disorder treatment setting: a preliminary study

Background

Clinicians collect session therapy notes within patient session records. Session records contain valuable information about patients' treatment progress. Sentiment analysis is a tool to extract emotional tones and states from text input and could be used to evaluate patients' sentiment during treatment over time. This preliminary study aims to investigate the validity of automated sentiment analysis on session patient records within an eating disorder (ED) treatment context against the performance of human raters.

Methods

A total of 460 patient session records from eight participants diagnosed with an ED were evaluated on their overall sentiment by an automated sentiment analysis and two human raters separately. The inter-rater agreement (IRR) between the automated analysis and human raters and IRR among the human raters was analyzed by calculating the intra-class correlation (ICC) under a continuous interpretation and weighted Cohen's kappa under a categorical interpretation. Furthermore, differences regarding positive and negative matches between the human raters and the automated analysis were examined in closer detail.

Results

The ICC showed a moderate automated-human agreement (ICC = 0.55), and the weighted Cohen's kappa showed a fair automated-human (k = 0.29) and substantial human-human agreement (k = 0.68) for the evaluation of overall sentiment. Furthermore, the automated analysis lacked words specific to an ED context.

Discussion/conclusion

The automated sentiment analysis performed worse in discerning sentiment from session patient records compared to human raters and cannot be used within practice in its current state if the benchmark is considered adequate enough. Nevertheless, the automated sentiment analysis does show potential in extracting sentiment from session records. The automated analysis should be further developed by including context-specific ED words, and a more solid benchmark, such as patients' own mood, should be established to compare the performance of the automated analysis to.

Canadian Occupational Performance Measure: Benefits and Limitations Highlighted Using the Delphi Method and Principal Component Analysis

Introduction

The objective of this study was to establish a baseline of current use in practice of the Canadian Occupational Performance Measure (COPM) by consulting 33 expert French occupational therapists, who trained in this method between 2012 and 2017 and use of the COPM with their clients. The areas of health intervention are pediatrics, psychiatry, neurology, and geriatrics. An email invitation to participate in the research was therefore sent to 113 occupational therapists. We received 33 responses.

Methods

A novel mixed method study combined a Delphi method with a lexical analysis of experts' responses and principal component analysis (PCA).

Results

In the last Delphi round, the consensus of the expert group was attained on 31 benefits and 1 limitation, confirming the generally positive influence of the COPM in French health services. Discussion. The COPM was clearly identified as a tool that supports occupational therapy clinical reasoning, facilitates team decision-making for care pathways, and enables people with disabilities and health conditions to make decisions for their care.

Conclusion

The Delphi study revealed that the COPM appears to be well adapted to French culture and should be widely incorporated into preregistration training.

Implementing Patient-Reported Outcomes to Improve the Quality of Care for Weight of Patients with Schizophrenia

"Enhancing QUality of Care In Psychosis" (EQUIP) was an eight-site clustered controlled trial of the implementation and effectiveness of patient-reported outcomes to support evidence-based practice and improve care for schizophrenia. Implementation sites chose to improve care for weight. Implementation included monitoring patient-reported outcomes using kiosks, patient and staff education, quality improvement teams, and phone care management. Qualitative and quantitative methods compared implementation and effectiveness between sites for 13 months. Eighty percent of 801 randomly selected patients were overweight. Two hundred one clinicians varied in competency. Baseline use of behavioral weight services was low. At implementation sites, patients became 2.3 times more likely to use weight services compared with control sites (95% CI, 1.5-3.6; χ² = 14.4; p < 0.01). There was no effect on the weight gain liability of medications prescribed. Controlling for baseline, patients' final weight at control sites was 5.9 ± 2.7 kg heavier than at implementation sites (F = 4.8, p = 0.03). Patient-reported outcomes can inform implementation of evidence-based practice and improvement in outcomes.

The impact of waiting time on patient outcomes: Evidence from early intervention in psychosis services in England

Recently, new emphasis was put on reducing waiting times in mental health services as there is an ongoing concern that longer waiting time for treatment leads to poorer health outcomes. However, little is known about delays within the mental health service system and its impact on patients. We explore the impact of waiting times on patient outcomes in the context of early intervention in psychosis (EIP) services in England from April 2012 to March 2015. We use the Mental Health Services Data Set and the routine outcome measure the Health of the Nation Outcome Scale. In a generalised linear regression model, we control for baseline outcomes, previous service use, and treatment intensity to account for possible endogeneity in waiting time. We find that longer waiting time is significantly associated with a deterioration in patient outcomes 12 months after acceptance for treatment for patients that are still in EIP care. Effects are strongest for waiting times longer than 3 months, and effect sizes are small to moderate. Patients with shorter treatment periods are not affected. The results suggest that policies should aim to reduce excessively long waits in order to improve outcomes for patients waiting for treatment for psychosis.

Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the StJohn's region.

Methods

Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery andwomen's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the StJohn's region, and separately for hospitals in the rest of the province.

Results

There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronaryartery by pass grafting (CABG) morbid event rate improved, although access to CABG was not optimal.

Conclusions

Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

Patient and Clinician Assessments of Symptomatology Changes on Older Adults Following a Psycho-educational Program for Depression and Anxiety

Important attention has been given to the assessment of patients' perspectives on treatment, especially as outcomes have been typically evaluated by clinicians. This study examined the association between patient and clinician ratings on perceived improvement and symptomatology changes for an older adult population participating in an ongoing psycho-educational program. Pre-post measures including depression (GDS), anxiety (BAI) and general well-being (GWBS) were collected in a sample of 34 older adults (age = 71.32 ± 6.46 years). Post-testing data included perceived improvement rated by patients, and clinician assessment of depressive symptoms (CS-GDS). Results indicate significant correlations between pre-post changes of the GDS and patients' PIQ (r = -0.37, n = 31, p < 0.05), but not on symptomatic changes of the BAI (r = 0.012, n = 32, p > 0.05) or the GWBS (r = 0.12, n = 31, p > 0.05). Relationships between patients' PIQ and post-ratings on GDS (r = -0.74, n = 33, p < 0.05) and CS-GDS (r = -0.48, n = 32, p < 0.05) are also significant. Results imply that pre-post improvement in depressive symptoms is associated with a patient's perceived improvement and that clinician and patient ratings on depression symptoms post-treatment were both inversely correlated to patients' perceived improvement. Findings suggest that the PIQ is a good indicator to assess symptomatic change by patients and clinicians although they are possibly placing attention on different aspects of treatment outcome, as indicated by differences on sub-scales of the PIQ. Clinicians possibly place a strong focus on assessments of depression symptomatology. Future studies may integrate simultaneous assessments of instruments exploring aspects other than depression, especially those examining representations of illness in older adults.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Unmet needs in the management of schizophrenia

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting

BACKGROUND

Despite growing interest and urges by leading experts for the routine collection of patient reported outcome (PRO) measures in all general care patients, and in particular cancer patients, there has not been an updated comprehensive review of the evidence regarding the impact of adopting such a strategy on patients, service providers and organisations in an oncologic setting.

METHODS

Based on a critical analysis of the three most recent systematic reviews, the current systematic review developed a six-method strategy in searching and reviewing the most relevant quantitative studies between January 2000 and October 2011 using a set of pre-determined inclusion criteria and theory-based outcome indicators. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to rate the quality and importance of the identified publications, and the synthesis of the evidence was conducted.

RESULTS

The 27 identified studies showed strong evidence that the well-implemented PROs improved patient-provider communication and patient satisfaction. There was also growing evidence that it improved the monitoring of treatment response and the detection of unrecognised problems. However, there was a weak or non-existent evidence-base regarding the impact on changes to patient management and improved health outcomes, changes to patient health behaviour, the effectiveness of quality improvement of organisations, and on transparency, accountability, public reporting activities, and performance of the health care system.

CONCLUSIONS

Despite the existence of significant gaps in the evidence-base, there is growing evidence in support of routine PRO collection in enabling better and patient-centred care in cancer settings.

Mental health care Monitor Older adults (MEMO): monitoring patient characteristics and outcome in Dutch mental health services for older adults

Information on which older adults attend mental health care and whether they profit from the care they receive is important for policy-makers. To assess this information in daily practice, the "Mental health care Monitor Older adults" (MEMO) was developed in the Netherlands. The aim of this paper is to describe MEMO and the older adults who attend outpatient mental health care regarding their predisposing and enabling characteristics and need for care. In MEMO all patients referred to the division of old age psychiatry of the participating mental health care organisations are assessed at baseline and monitored at 4, 8 and 12-month follow-up. Primary outcomes are mental and social functioning, consumer satisfaction, and type of treatment provided (MEMO Basic). Over the years, MEMO Basic is repeated. In each cycle, additional information on specific patient groups is added (e.g. mood disorders). Data collection is supported by a web-based system for clinicians, including direct feedback to monitor patients throughout treatment. First results at baseline showed that the majority of patients that entered the division of old age psychiatry was female (69%), had low education (83%), lived alone (53%), was depressed (42%) and had a comorbid condition (82%). It seemed that older immigrants were not sufficiently reached. The current study is the first in the Netherlands to evaluate patient characteristics and outcome in mental health care provided for older adults in day-to-day practice. If MEMO works out successfully, the method should be extended to other target groups.

The use of a Cumulative Needs for Care Monitor for individual treatment v. care as usual for patients diagnosed with severe mental illness, a cost-effectiveness analysis from the health care perspective

AIMS

To study the systematic assessment of need for care and clinical parameters for use in treatment plans in patients diagnosed with severe mental illness.

METHODS

The Cumulative Needs for Care Monitor (CNCM) includes various validated instruments, such as the Camberwell Assessment of Need. A Markov-type cost-effectiveness model (health care perspective, 5-year time horizon) was used to compare CNCM with care as usual (CAU). Two studies were used to determine model parameters: a before–after study (n = 2155) and a matched-control study (n = 937).

RESULTS

The CNCM may lead to a gain in psychiatric functioning according to the models. CNCM patients remain in (outpatient) care, while CAU patients drop out more frequently. There is only a small difference in inpatient care. As a result, average costs per patient in the CNCM group are between €2809 (before–after model) and €5251 (matched-control model) higher. The iCER was between €45 127 and €57 839 per life year without psychiatric dysfunction gained.

CONCLUSIONS

CNCM may be only cost-effective when willingness to pay for a life year without psychiatric dysfunction is higher than €45 000. However, this result is highly sensitive to the level of psychiatric dysfunctioning in patients who do not receive care.

Schizophrenia in real life: courses, symptoms and functioning in an Italian population

Background

In the general belief, schizophrenia is associated with the concepts of seriousness, incurability, dangerousness: this is incorrect. In recent decades, the interest in course studies increased and different trends emerged, not necessarily chronic, with the possibility of remission.

The plan of this research was to draw a picture of the schizophrenia syndrome in a specific geographic area, in the past and at present time: this allows to detect needs, weaknesses and strengths, for a better planning of future interventions.

Methods

The course of all cases diagnosed as schizophrenia (N = 1,759) in the period 1978–2008, was retrospectively studied in the entire population of an Italian province by observing, for a mean period of 12 years per person, age at first psychiatric consultation, number and length of admissions for both acute symptoms and residential-rehabilitation programs, number of interventions in outpatients. The cases under treatment (N = 842), were evaluated in terms of symptoms, using the Brief Psychiatric Rating Scale, and in terms of functioning, using the Personal and Social Functioning Scale.

Results

The disease course differs significantly between genders: males have an earlier age at first consultation (about 7 years earlier), higher admission rates, greater number of outpatient interventions and personal and social functioning significantly worse.

Hospitalization resulted often unnecessary: 23.1% of cases were never hospitalized and 67.2% spent less than one week per year in hospital.

A quarter of the cases meets the international criteria for remission and more than 75% are asymptomatic or mildly symptomatic; only 5.3% of cases shows severe symptoms. However, Personal and Social Functioning highlights, in about 1/3 of cases, relevant or serious problems mainly in Work and Relationships areas, whilst Aggressiveness is a serious problem only in 9%.

Conclusions

In this population, schizophrenia in real life shows great individual variability in course, symptoms and functioning: in most cases nowadays it appears a less severe and chronic disease than in the past, but further improvements are needed on disability prevention and social inclusion.

Clinicians' perspectives on a Web-based system for routine outcome monitoring in old-age psychiatry in the Netherlands

BACKGROUND

In health care, the use of physical parameters to monitor physical disease progress is common. In mental health care, the periodic measurement of a client's functioning during treatment, or routine outcome monitoring, has recently become important. Online delivery of questionnaires has the potential to reduce clinicians' resistance to the implementation of routine outcome monitoring. Online delivery enables clinicians to receive results on a questionnaire in a graphic directly after data entry. This gives them insight into the progress of a client at a single glance.

OBJECTIVE

To explore clinicians' perspectives on a routine outcome monitoring procedure where questionnaires and feedback on scores were delivered online. Questionnaires could also be filled out on paper and then entered into the online system by a research assistant.

METHODS

In 2009 we sent an online survey, consisting of five yes-or-no questions and six open-ended questions, to all clinicians in the 14 mental health care organizations working with the routine outcome monitoring system in the Netherlands. Of the 172 clinicians contacted, 80 (47%) opened the link and 70 of these 80 (88%) clinicians completed the survey.

RESULTS

Clinicians seldom used the graphical feedback from the Web-based system, which indicates that direct feedback on scores did not enhance the implementation of routine outcome monitoring. Integration into the electronic patient record and more training on interpretation and implementation of feedback in daily practice were seen as the primary points for further improvement. It was mainly the availability of a research assistant that made the routine outcome monitoring procedure feasible.

CONCLUSIONS

Without a research assistant and training in the interpretation of outcomes, software programs alone cannot ensure effective implementation of monitoring activities in everyday practice.

How valid and responsive are generic health status measures, such as EQ-5D and SF-36, in schizophrenia? A systematic review

OBJECTIVES

Generic health status measures such as the short form health survey (SF-36) and EuroQol-5D (EQ-5D) are increasingly being used to inform health policy. They are claimed to be applicable across disease areas and have started to be used within mental health research. This review aims to assess the construct validity and responsiveness of four generic health status measures in schizophrenia, including the preference-based SF-6D and EQ-5D.

METHOD

A systematic review of the literature was undertaken. Ten databases were searched from inception to August 2009 and reference lists scrutinized to identify relevant studies. Studies were appraised and data extracted. A narrative synthesis was performed of the evidence on construct validity including known groups validity (detecting a difference in health-related quality of life (HRQL) scores between two different groups such as samples from the general population and people with schizophrenia), convergent validity (strength of association between generic HRQL and other measures (e.g., symptom or functional), and responsiveness. Responsiveness was considered by: 1) differences in generic HRQL measure scores in responders/non-responders and 2) correlation between changes on generic HRQL measures and changes in specific measures obtained from patients and clinicians.

RESULTS

Thirty-three studies were identified that provided data on the validity and/or responsiveness of the instruments. Most of the evidence concerns the SF-36 and EQ-5D, and for these instruments there was evidence for known group validity. The evidence for convergent validity and responsiveness was mixed, with studies presenting contradictory results.

CONCLUSION

Although the evidence base is limited in a number of important respects, including problems with the measures used to develop constructs in the validation studies, it is sufficient to raise doubts about the use of generic measures of health like the EQ-5D and SF-36 in patients with schizophrenia.

Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

BACKGROUND

Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use.

OBJECTIVES

To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services.

METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews.

MAIN RESULTS

We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes.

AUTHORS' CONCLUSIONS

Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.

Routine administration of the Canadian Occupational Performance Measure: effect on functional outcome

BACKGROUND/AIM

Routinely using outcome measures as an integral component of practice has been encouraged for decades yet has not been widely adopted. There are many reasons to measure outcomes yet any positive effect of measurement on our programs or clients has not been substantiated. If the time-consuming nature of outcome measurement is to be encouraged, we need to begin addressing larger questions of the value of outcome measurement on care and outcomes. This cohort study evaluated the impact of routinely administering the Canadian Occupational Performance Measure on client outcomes on a geriatric rehabilitation unit.

METHODS

Changes in Functional Independence Measure™ scores between an experimental group (n = 45) that received the routine use of the Canadian Occupational Performance Measure for evaluation/planning versus a historical comparison group (n = 58) that received 'usual' care were analysed using generalised linear modeling.

RESULTS

Both groups had significant changes in Functional Independence Measure™ scores over time. Results for differences between groups were inconclusive with a significantly underpowered analysis; however, results suggest that a medium to large effect of this intervention cannot be expected.

CONCLUSIONS

Results are significant for the field of routine outcome measurement, suggesting that when adding the Canadian Occupational Performance Measure to routine assessment within an inpatient rehabilitation setting, substantially improved Functional Independence Measure™ score outcomes should not be expected. The value of routine outcome measurement on client outcomes remains largely unexplored. Routinely, using outcome measures requires additional research to determine the specific benefits to our programs and client outcomes.

The Met Needs Index: a new metric for outcome assessment in mental health services

BACKGROUND

No apt method has been available to assess and monitor the responsiveness of services in meeting ongoing needs of patients with long-term mental illness. The present study examines the utility of a new metric for such a purpose, the Met Needs Index (MNI), applied to the Camberwell Assessment of Need (CAN).

METHODS

The MNI was estimated as an aggregated measure of met need or beneficial outcome, based on annual staff rated CAN-assessments of 321 outpatients (76% psychotic disorders) in psychiatric care during 7 years. Corresponding confidence intervals were estimated with the bootstrap percentile method.

RESULTS

The overall MNI was estimated at 0.71 (95% CI 0.69-0.74), indicating that identified needs in general were met during 71% of the intervals between the annual assessments. However, the MNI for specific need domains of the CAN ranged from 0.89 (95% CI 0.84-0.93) for 'food' to 0.11 (95% CI 0.07-0.16) for 'sexual expression', indicating a significant variation in responsiveness of services to different types of need in this patient population.

CONCLUSIONS

The MNI seems to be a useful and powerful metric for outcome assessment and monitoring of psychiatric services from a needs assessment approach.

Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis

BACKGROUND

Feedback of treatment outcome during the course of therapy (outcome management) is increasingly considered to be beneficial for improving the quality of mental healthcare.

AIMS

To review the impact of feedback of outcome to practitioners and/or patients in specialist mental health services.

METHOD

A systematic search and meta-analysis of controlled trials using outcome management in mental health services published in English or German language.

RESULTS

Twelve studies met inclusion criteria. Feeding back outcome showed a small, but significant (d = 0.10; 95% CI 0.01-0.19) positive short-term effect on the mental health of individuals that did not prevail in the long run. Subgroup analysis revealed no significant differences regarding feedback modalities. Outcome management did not contribute to a reduction of treatment duration.

CONCLUSIONS

Evidence on the effects of outcome management in mental healthcare is promising. More targeted research is needed in order to identify the effective ingredients of outcome feedback and to assess its cost-effectiveness.

Organizational change to transfer knowledge and improve quality and outcomes of care for patients with severe mental illness: a systematic overview of reviews

OBJECTIVE

To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results.

METHOD

We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change.

RESULTS

A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance.

CONCLUSIONS

There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.

A Population-based Needs Assessment for Mental Health Services

A needs assessment was done to objectively evaluate client need and determine gaps between these needs and the services provided by mental health services. The services included were standard case management, assertive case management and residential care across the Fraser Health Region in British Columbia, Canada. Assessments involved collection of data on current symptoms, functioning, and service use and needs. Results showed many specific areas where client needs were under met. A level-of-care planning model was applied to the data and results suggest that a high percentage of clients may be in fact receiving too high or too low a level of care for their needs. This method of performing a population-based needs assessment provided findings that have proved useful for planning purposes in order to ensure that community mental health services better match client need.

Outcome measures and needs assessment tools for schizophrenia and related disorders

BACKGROUND

There has been a recent trend to encourage routine outcome measurement and needs assessment as an aid to decision making in clinical practice and patient care. Standardised instruments have been developed which measure clinical symptoms of disorders such as schizophrenia, wider health related quality of life and patients' needs. Such measures might usefully be applied to aid the recognition of psychosocial problems and to monitor the course of patients' progress over time in terms of disease severity and associated deficits in health related quality of life. They might also be used to help clinicians to make decisions about treatment and to assess subsequent therapeutic impact. Such an approach is not, however, without cost and the actual benefit of the adoption of routine outcome and needs assessment in the day-to-day care of those with schizophrenia remains unclear.

OBJECTIVES

To establish the value of the routine administration of outcome measures and needs assessment tools and the feedback they provide in improving the management and outcome of patients with schizophrenia and related disorders.

SEARCH STRATEGY

The reviewers undertook electronic searches of the British Nursing Index (1994 to Sept 1999), the Cochrane Library (Issue 2, 2002), the Cochrane Schizophrenia Group Trials Register (2002), EMBASE (1980-2002), MEDLINE (1966-2002), and PsycLIT (1887-2002), together with hand searches of key journals. References of all identified studies were searched for further trials, and the reviewers contacted authors of trials.

SELECTION CRITERIA

Randomised controlled trials comparing the feedback of routine standardised outcome measurement and needs assessment, to routine care for those with schizophrenia.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently. Studies which randomised clinicians or clinical teams (rather than individual patients) were considered to be the most robust. However only those which took account of potential clustering effects were considered further. Where possible and appropriate, risk ratios (RR) and their 95% confidence intervals (CI) were calculated. For continuous data Weighted Mean Differences (WMD) were calculated. Data were inspected for heterogeneity.

MAIN RESULTS

No randomised data were found which addressed the specified objectives. One unpublished and one ongoing trial was identified.

REVIEWER'S CONCLUSIONS

The routine use of outcomes measures and needs assessment tools is, as yet, unsupported by high quality evidence of clinical and cost effectiveness. Clinicians, patients and policy makers alike may wish to see randomised evidence before this strategy is routinely adopted.